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Fibroids on the uterus

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Q:I am 34 and married. As yet my husband and I have no children. I went to my GP recently, complaining of irregular periods. He suspected that I was pregnant and sent me to a consultant gynaecologist, who told me that I had a fibroid on my uterus

A:Although many consultants treat fibroids by removing the womb, this is becoming an increasingly outmoded treatment; some surgeons believe that since the uterus is basically healthy, hysterectomy is never justified.

The problem with fibroids is that we understand so little about why they develop. They are the most common tumours on female reproductive organs, occurring in about a fifth of all women; they are also the most common justification for hysterectomy, often in women in their twenties or thirties who haven't yet had children.

Although these tumours, also called myomas, can be troublesome, causing heavy, prolonged or irregular periods, infertility, pain during intercourse, in many cases they cause no problems and they are almost never cancerous (less than .2 per cent have been found to be malignant).

They come in all forms protruding from the outer surface of the uterus (subserous), buried inside the wall of the womb (intramural), or under the entrometrium (the blood vessel rich lining), from the endometrial lining into the uterine cavity (submucous) or on stalks (pedunculated), either outside or inside the uterus. Most fibroids grow inside a capsule, which acts as a clear border between fibroid and uterine wall; others, particularly those left to grow over time become invasive, growing roots into the normal uterine tissue. They are three times as common in black women as white, (although they cause more problems with infertility in white women, not in black) and possibly hereditary.

What we do know about fibroids is that they are oestrogen dependent (ie, they get worse when oestrogen levels are abnormally high, which occurs in women who are overweight, low in certain nutrients or pregnant). We also know that they grow slowly, and usually don't cause problems except between the ages of 35 and 45.

After the menopause, with the diminishment of oestrogen, fibroids shrink (so if you're near to 50 and have fibroids, just hold on a few years and you can avoid an operation).

In many cases, fibroids cause no problem, but it all depends on where they are placed. Subserous fibroids often cause the fewest problems, although women can begin to become aware of a mass in their abdomen. It is the submucous fibroids that cause heavy periods, and those on stalks can twist and become painful or descend through the cervix. Pedunculated and intramural fibroids cause cause infertility or recurrent miscarriages.

It is almost certain that you can avoid a hysterectomy. Even orthodox medicine offers a number of possible options to help preserve your fertility.

The standard alternative to hysterectomy used to be myomectomy (that is, removal of the fibroids). The surgeon would make a low abdomenal incision and remove each fibroid, one by one. The arguments against this surgery are that the patient may suffer from extensive bleeding at each removal site (more than from a hysterectomy) and that fibroids can grow back at the excision site. (Evidence shows that there is only a 2 to 3 per cent regrowth rate, although fibroids in general can recur in between 5 to 50 per cent of cases.) Myomectomy often can't get to all the fibroids inside the womb.

If your fibroids are small and only protrude into the uterine cavity, you could avoid major surgery by undergoing an endometrial resection or ablation, which involves using a resectoscope or hysteroscope, a long, thin gadget the surgeon inserts into the vagina with either a laser or a tiny electrical loop on one end and a viewer on the other. During the procedure, which takes less than an hour and can often be done with a sedative and local anaesthetic, the surgeon guides his instruments through his viewfinder and either shaves off the fibroids with the electric current or cuts them with the laser. Both techniques have the advantage over a scalpel of sealing blood vessels, so bleeding is reduced.

It should be mentioned that both techniques have also been offered to cut away the entire womb lining, which ends fertility and shrinks the womb. Often pressed upon women past their childbearing years, this technique, hailed as a medical breakthrough for women suffering from heavy periods, has caused a number of problems (see WDDTY vol 2 no 7).

If abdominal surgery is the only option, you could find a surgeon who either employs laparoscopy (make sure that he is very experienced) or one who employs the newest techniques like those described by American gynaecologist Dr Vickie Hufnagel. Instead of cutting out each fibroid individually a single incision is made, through which she can view all fibroids inside and out. Employing drugs to control bleeding, she then excises each fibroid with a laser, which again, minimizes bleeding. Where necessary, she performs reconstructive surgery, making any repairs to the uterus and resuspending it on its supporting ligaments. In most cases myomectomy preserves fertility; one woman we've heard of had such an operation at 40 and went on to have a baby at home two years later.

If the fibroids aren't causing severe pain, since they grow slowly, it might be worth trying a non surgical approach with an experienced nutritional therapist before you submit to the knife. Because heavy bleeding and fibroids get worse when oestrogen levels are out of balance, it may be that fibroids can be controlled by nutrients such as iron and magnesium and particularly essential fatty acids. In the UK, Prof Howard Jacobs of Middlesex Hospital is an expert in hormone control through diet. It may also help to take up regular aerobic exercise which helps to reduce body fat, which can also reduce oestrogen levels. You could also try working with an experienced herbalist; helonias root and agnus castus may help to regulate your oestrogen levels.